APPLICATION FOR CJA PANEL MEMBERSHIP Please answer all questions. If a question is not applicable, indicate this by marking "N/A." GENERAL 1. 2. 3. Full name: Business name Office address: City Office Phone Email EDUCATION 4. Colleges and universities attended, dates, and degrees: State Fax Zip Cell Phone PROFESSIONAL ADMISSIONS 5. List all courts (including state bar admissions)in which you are presently admitted to practice, giving the dates of admission in each instance: Court or Administrative Body U.S. District Court for District of Utah Utah State Bar Bar No. ______________ Date of Admission Bar No. ______________ 6. Have you ever been disciplined or cited for a breach of ethics or unprofessional conduct by any court, administrative agency, bar association, or other professional group? Yes No. If yes, give particulars. LAW PRACTICE 7. Provide the following information for your employment for the past five years. Organization Address Position Dates 8. Describe the general nature of your current practice including any legal specialties and character of your typical clients; also, if your practice is substantially different now than previously, give details of prior practice. 9. What percentage of your court appearances in the last five years were in criminal cases in: 1. Federal courts 2. State or local courts % % Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR CJA PANEL MEMBERSHIP 10. 11. 12. During the past five years, what percentage of your practice has been criminal trial practice? How frequently have you appeared in court? a) Have you ever been sued by a client? _______ Yes _____ % times per month. No. If yes, give particulars. b) Have you or your professional liability insurance carrier ever settled a claim against you for professional malpractice? Yes No. If yes, give particulars, including the amounts involved. CONDUCT 13. Have you ever been charged in any civil or criminal proceedings with conduct alleged to involve moral turpitude, dishonesty, or unethical conduct? Yes No. If yes, give particulars. 14. a) Have you ever been arrested, charged, or convicted for violation of any federal law, state law, county or municipal law, regulation, or ordinance? Yes No. If yes, give details. (Do not include traffic violations for which a fine of $200 or less was imposed unless it also included a jail sentence.) b) Have you, to your knowledge, ever been under federal, state or local investigation for possible violation of a criminal statute? Yes No. If yes, give particulars. 15. Have you in the last 10 years (i) been hospitalized due to injury or serious mental or physical illness or drug or alcohol addiction, or (ii) been prevented from working or otherwise incapacitated for a period in excess of ten days due to injury or illness, drug or alcohol addiction? If so, give the particulars, including the causes, the dates, the places of confinement, and the present status of the conditions which caused the confinement or incapacitation. SUPPLEMENTAL INFORMATION 16. State any achievements or actions you have accomplished, demonstrating your commitment to equal justice under the law. 17. State any other pertinent information reflecting positively or adversely on you which you believe should be disclosed. Language Proficiency (including sign language): 18. Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR CJA PANEL MEMBERSHIP I am a member in good standing of the Bar of this Court and a registered electronic filer, and a member in good standing of the Utah State Bar and that I will strictly observe the rules of professional conduct adopted by the United States District Court for the District of Utah. I declare under penalty of perjury that the information in this application is true and correct. Signature of Applicant Date CONFIDENTIALITY STATEMENT This form will be kept confidential and will be examined only by the judges of the district court and others necessary to review of panel applications. Applications submitted by May 31 and November 30 are reviewed in June and December, respectively. Submit this form to: Chief Magistrate Judge Brooke C. Wells Room 431 Frank E. Moss United States Courthouse 350 South Main Street Salt Lake City, UT 84101 . Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com